Robotic Exploration and Suture Removal Following Sacrospinous Ligament Suspension

To demonstrate a deep robotic dissection of the sacrospinous ligament because of a suture abscess after a failed vaginal approach.

A stepwise demonstration of the procedure and critical anatomy with narrated video.

A tertiary care academic center. A 71-year-old patient with a pelvic abscess noted on magnetic resonance imaging with persistent vaginal bleeding after sacrospinous ligament suspension using permanent, multi-filament suture. Despite multiple vaginal attempts to remove the suture, the abscess and suture persisted. A decision was made to proceed with a robotic exploration.

Sacrospinous ligament suspension is a procedure supporting the vaginal apex by securing it to the sacrospinous ligament, typically on the right side. It is a durable, native tissue repair performed through extraperitoneal vaginal dissection of the pararectal space. With suture-related complications, to release the stitch, a vaginal approach is often successful and less invasive. However, it may be challenging to dissect this plane because of adhesions and difficult visualization. In this video, we demonstrate a robotic-assisted abdominal approach developing the pararectal space and identifying deep pelvic space lesions when vaginal attempts have failed. The top-down approach offers better visualization of surrounding critical structures, overcoming the limitations of the vaginal approach with limited visualization. However, this requires advanced knowledge and comfort with deep retroperitoneal structures.

The robotic approach offers an alternative to the vaginal approach and should be considered when the vaginal approach fails or is considered not feasible.